早期抗反轉錄病毒治療 (ART) 對 HIV 感染者死亡率的益處

資料來源：http://www.thelancet.com/hiv / Vol9 June 2022 / 財團法人台灣紅絲帶基金會編譯

  及早立即開始抗反轉錄病毒治療 (ART) 對於降低 HIV 感染者的死亡風險和提高生活品質非常重要。在《刺胳針愛滋病毒》中，Fangfang Chen 及其同事報告說，HIV 感染者在確診後的第一年自殺死亡率特別高（標準化死亡率 9·2，95% CI 8·5-9·8），尤其是在前 3 個月（98·1、93·1–103·4）。早期的抗反轉錄病毒治療可能使愛滋病毒感染者獲得更大的社會支持並增強復原力。診斷較晚或從未接受抗反轉錄病毒治療的人通常患有晚期疾病，存活率低，有限的治療選擇可能會增加自殺風險。因此，應該重點關注針對愛滋病毒感染者的自殺預防計畫，特別是考慮到 COVID-19 大流行對公眾心理健康的影響。

  中國之前的研究顯示，早期啟動抗反轉錄病毒療法可以降低病毒學失敗、從照護體系流失（減員）和死亡率的風險。早期啟動抗反轉錄病毒療法（CD4 計數為 500 個細胞/µL）的病毒學失敗率較低 (6·6%) 比在 ART 前其 CD4 計數低於 350 個細胞/µL 時開始 (9·0%)。與立即 ART 相比，延遲 ART 增加了流失率：調整後的風險比 1·3 (95 % CI 1·2–1·5) 延遲 31–90 天，1·9 (1·7–2·1) 延遲 91–365 天，2·2 (2·0–2·5)延遲 1 年或更長時間。此外，早期和立即開始 ART 可以進一步預防 HIV 在人群和社區層面的二次傳播。一項在現實世界環境中進行的研究顯示，在人群層面進行「治療作為預防」的 HIV 傳播減少了 53·6% (95% CI 42·1–65·1)。病毒載量低於 50 拷貝/mL 的治療結果為 61·1% (95% CI 51·0–71·1)。

  總之，在中國已經觀察到早期和立即開始抗反轉錄病毒療法的益處，包括減少與愛滋病毒相關的死亡（透過減少自殺、減少流從和病毒學失敗）和預防二次傳播。由於中國的晚期診斷率從 2012 年到 2018 年並沒有下降，及時啟動 ART 仍然具有挑戰性，因此無論 CD4 計數如何，早期診斷和立即啟動 ART 都應該在 HIV 預防綜合規畫中予以強調和控制。

我們聲明沒有競爭利益。這項工作得到了國家自然科學基金（82160636、11971479）、廣西愛滋病防治與轉化重點實驗室（ZZH2020010）、廣西八桂榮譽獎學金和中國傳染病防治國家重點實驗室的支持。

Yihong Xie, Jinhui Zhu, Guanghua Lan, *Yuhua Ruan  ruanyuhua92@chinaaids.cn

廣西醫科大學流行病學與生物統計學系，廣西南寧（YX）；廣西省疾病預防控制中心重大傳染病防治與生物安全應急響應重點實驗室，廣西南寧（JZ，GL，YR）；傳染病預防控制國家重點實驗室, 國家愛滋病/性病預防控制中心, 中國疾病預防控制中心, 傳染病診療協同創新中心, 北京, 中國 (YR)

Benefits of early ART initiation on mortality among people with HIV

  Initiating antiretroviral therapy (ART) early and immediately is important for reducing the risk of mortality and improving quality of life among people with HIV. In The Lancet HIV, Fangfang Chen and colleagues 1 reported that suicide mortality in people with HIV was particularly high in the first year after diagnosis (standardised mortality ratio 9·2, 95% CI 8·5–9·8), especially in the first 3 months (98·1, 93·1–103·4). Early ART initiation might allow people with HIV to receive greater social support and enhance resilience. People diagnosed late or who are never on ART usually have advanced stage disease with low survival rates2 and the limited treatment options might increase the risk of suicide. Thus, there should be focus on suicide prevention programmes for people with HIV, especially considering the effect of the COVID-19 pandemic on public mental health.

  Previous studies in China have shown that early initiation of ART can reduce the risks of virological failure, loss to care (attrition), and mortality.3–5 Early ART initiation (with CD4 counts of 500 cells per µL) had a lower virological failure rate (6·6%) than initiation at pre-ART CD4 counts of less than 350 cells per µL (9·0%).4 Delayed ART increased the attrition rate when compared with immediate ART: adjusted hazard ratio 1·3 (95% CI 1·2–1·5) for 31–90 days delayed, 1·9 (1·7–2·1) for 91–365 days delayed, and 2·2 (2·0–2·5) for 1 year or longer delayed.4 Moreover, early and immediate initiation of ART can further prevent HIV secondary transmission at the population and community level. A study in a real-world setting showed a 53·6% (95% CI 42·1–65·1) reduction in HIV transmission for treatmentas-prevention at the population level.5 The preventive efficacy for HIV transmission among patients on treatment with viral load less than 50 copies per mL was 61·1% (95% CI 51·0–71·1). 

  In summary, benefits of early and immediate initiation of ART had been observed in China, including reduced HIV-related death (by reducing suicides, attrition, and virological failure) and the prevention of secondary transmission. Because the rate of late diagnosis in China did not decrease from 2012 to 2018 and initiating ART in a timely manner is still challenging,1 early diagnosis and the immediate initiation of ART, regardless of CD4 counts, should be emphasised in comprehensive programmes of HIV prevention and control. 

We declare no competing interests. This work was supported by National Natural Science Foundation of China (82160636, 11971479), Guangxi Key Laboratory of AIDS Prevention Control and Translation (ZZH2020010), Guangxi Bagui Honor Scholarship, and Chinese State Key Laboratory of Infectious Disease Prevention and Control. 

Yihong Xie, Jinhui Zhu, Guanghua Lan, *Yuhua Ruan ruanyuhua92@chinaaids.cn 

Department of Epidemiology and Biostatistics, Guangxi Medical University, Nanning, Guangxi, China (YX); Guangxi Key Laboratory of Major Infectious Disease Prevention Control and Biosafety Emergency Response, Guangxi Center for Disease Control and Prevention, Nanning, Guangxi, China (JZ, GL, YR); State Key Laboratory of Infectious Disease Prevention and Control, National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Beijing, China (YR)